Policy Updates April 2020

Important Information

Note - Some updates require the user to be logged into the website using username and password. Each secure section or policy will be marked with an asterisk *

Policies Update to Coverage
Policies With a Reduction in Coverage
Ambulance Services - (R18)*
  • Effective for claims processed on or after April 5, 2020, we will update the Ambulance Services Reimbursement Policy (R18) to deny Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes used to bill for ambulance services and supplies when billed separately.
  • This initiative will only affect nonparticipating providers.
Genetic Testing Panels Reimbursement Policy - (R28)*
  • Effective for claims processed on or after April 6, 2020, we will rebundle CPT codes used to bill for individual tests that comprise a molecular cancer laboratory panel into a single panel code.
  • Submitted claims will be processed and reimbursed using the appropriate CPT panel code.
  • We will also no longer require precertification for certain CPT codes for individual tests.
Serological Testing for Inflammatory Bowel Disease - (0121)
  • Effective for claims processed on or after April 15, 2020, we will deny CPT codes for serum drug level testing when billed with an inflammatory bowel disease (IBD) diagnosis.
  • Serum drug level testing for IBD testing is considered experimental, investigational, and unproven (EIU).
  • We will update the Serological Testing for Inflammatory Bowel Disease - (0121) medical coverage policy to reflect this change.
Policies Status Details
Medical Coverage Policies
Unless otherwise noted, the following medical coverage policies were modified effective April 15, 2020:
Site of Care: High-Tech Radiology – (0550) New
  • Originally provided advance notification of new policy on December 15, 2019.
  • Note: Implementation is postponed until further notice.
Balloon Sinus Ostial Dilation for Chronic Sinusitis and Eustachian Tube Dilation - (0480) Modified
  • Minor changes in coverage criteria/policy:
    • Reformatted for clarity.
Blepharoplasty, Reconstructive Eyelid Surgery, and Brow Lift - (0045) Modified
  • Important changes in coverage criteria:
    • Removed criterion for epiphora.
Emerging Surgical Procedures for Glaucoma - (0035) Modified
  • Important changes in coverage criteria:
    • Changed from not covered to covered:
      • One or two iStent Trabecular Micro Bypass Stent or iStent Inject.
      • Hydrus Microstent.
      • Xen Gel Stent.
    • Added viscocanaloplasty to existing not covered policy statement.
Home Ventilators - (0546) Modified
  • Important change in coverage criteria, effective April 1, 2020:
    • Added coverage for HCPCS code E0467 (Home ventilator, multifunction device) if specific criteria are met.
Otoplasty and External Ear Reconstruction - (0335) Modified
  • Important changes in coverage criteria:
    • Added coverage for external ear reconstruction when defect prevents functional ability to use eyewear for correction of visual loss.
    • Added coverage of ear molding if there is a functional impairment of hearing associated with external ear deformity.
Serological Testing for Inflammatory Bowel Disease - (0121) Modified
  • Originally provided advance notification of important changes in coverage criteria on January 15, 2020:
    • Expanded existing experimental, investigational, or unproven (EIU) policy statement to include serum drug level testing is EIU for management of inflammatory bowel disease.
    • Updated existing policy statement to address the class of drugs used to treat inflammatory bowel disease rather than listing specific drugs:
      • Specific drugs used as examples only.
    • Updated test panel examples to read test name and removed drug name being tested.
Transcatheter Ablation for the Treatment of Supraventricular Tachycardia in Adults - (0529) Modified
  • Important change in coverage criteria:
    • Updated existing policy statement noting transcatheter ablation is considered medically necessary for cavotricuspid isthmus atrial flutter.
Wheelchairs/Power Operated Vehicles - (0030) Modified
  • Important changes in coverage criteria:
    • Updated policy statement to address noncoverage of wheelchair-mounted assistive robotic arm (e.g., KINOVA JACO® Assistive Robotic [KINOVA, Inc., Boisbriand QC, Canada]).
Policies Status Details
American Specialty Health (ASH) Cobranded Clinical Practice Guidelines (CPGs)
  • Three Cigna-ASH CPGs were updated with no changes in coverage
Policies Status Details
Cigna-eviCore Cobranded Guidelines
  • Updated the Gastrointestinal Endoscopic Procedure Esophagogastroduodenoscopy (GES) guidelines:
    • Added qualifying physical and lab findings by which gastrointestinal (GI) bleeding and iron deficiency should be demonstrated.
    • Added criteria for the following:
      • Epigastric pain suggesting pancreatic or biliary source.
      • Failure of antisecretory medical therapy.
      • Appropriate cardiac workup for noncardiac chest pain.
      • Absence of dysplasia based on risk stratification.
      • Added follow up to hyperplastic polys with dysplasia.
      • Evaluating extra-esophageal symptoms of gastroesophageal reflux disease (GERD).
    • Added new indication for an EGD and atrophic gastritis.
Policies Status Details
Administrative Policies
Anti-Stockpiling Limits – (A009) New
  • New administrative policy, effective April 3, 2020:
    • Prevents stockpiling, misuse and/or overuse of medications.
    • Additional products in shortage or at risk of shortage may be added to protect availability.
    • Products no longer at threat of shortage will be removed.
    • Specific terms of applicable benefit plan document continue to apply regarding copay or coinsurance and may include other plan limits, such as prior authorization, step therapy, or coverage based upon the plan’s prescription drug list.
Policies Status Details
Pharmacy (Drugs & Biologics) Policies
Unless otherwise noted, the following pharmacy coverage policies were modified effective April 1, 2020:
Peanut (arachis hypogaea) allergen powder-dnfp – (2004) New
  • Supports pharmacy prior authorization of Palforzia.
Oncology Medications – (1403) Modified
  • Minor changes in coverage criteria/policy:
    • Added to pharmacy benefit table:
      • Ayvakit (avapritinib)
      • Tazverik (tazemetostat).
    • Added to medical precertification table:
      • Zirabev (bevacizumab-bvzr).
      • Trazimera (trastuzumab-qyyp).
      • Ruxience (rituximab-pvvr).
Penicillamine and trientene hydrochloride – (1703) Modified
  • Important changes in coverage criteria:
    • Added generic penicillamine tablets as a required alternative for brand Cuprimine, Depen, and Syprine:
      • Based on business decision and new generic for Depen (generic penicillamine tablets).
Topical Acne - (P0049) Modified
  • Important changes in coverage criteria:
    • Added Aklief (trifarotene) policy supporting business changes requiring medical necessity review for coverage, effective April 25, 2020.
Human Papillomavirus Vaccine - (6018) Retired
Policies Status Details
CareAllies Medical Necessity Guidelines
  • No updates for April 2020
Policies Status Details
Precertification Policies*
Policies Status Details
Reimbursement Policies*
Ambulance Services - (R18) Modified
  • Important changes:
    • Updated to note Cigna does not provide separate reimbursement for services and supplies provided during ambulance transportation:
      • They are included in the ambulance transportation payment.
Policies Status Details
Code Edit and Policy Guidelines Modified
  • Important changes effective May 16, 2020:
    • ClaimsXten will be updated to Second Quarter Knowledge Base content and NCCI Version 26.1 for all medical and behavioral claims we process.

These policies apply to health benefit plans administered by Cigna companies and are intended to provide guidance in interpreting certain standard Cigna benefit plans. Please note, the terms of a customer's particular benefit plan document [Group Service Agreement, Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] July differ significantly from the standard benefit plans upon which these policies are based. For example, a customer's benefit plan document July contain a specific exclusion related to a topic addressed in a policy. In the event of a conflict, a customer's benefit plan document always supersedes the information in the policies.
In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including these policies and; 4) the specific facts of the particular situation. These policies relate exclusively to the administration of health benefit plans and are not recommendations for treatment and should never be used as treatment guidelines. In certain markets, delegated vendor guidelines July be used to support medical necessity and other coverage determinations.